=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548233372
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFERSON COUNTY FIRE PROTECTION DISTRICT NO 3
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2006
-----------------------------------------------------
Last Update Date | 09/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7650 OAK BAY RD
-----------------------------------------------------
City | PORT LUDLOW
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98365-9634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-437-2236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3510
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-3510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-394-7030
-----------------------------------------------------
Fax | 360-394-7097
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FIRE CHIEF
-----------------------------------------------------
Name | ED WILKERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-437-2236
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 16D03
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------